Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Inborn Errors of Metabolism
Document related concepts
Transcript
Board Review 6/7/2013 What is your favorite letter? A. C B. D C. E D. A E. B Assess a patient with head trauma and determine if a significant intracranial injury (ICI) has resulted Recognize an increase in intracranial pressure Initial management of acute CNS trauma Outpatient management of minor head trauma Primary injury Mechanical damage to skull/tissue Shearing forces vessel rupture bleeds Secondary injury Ongoing derangement to neuronal cells due to: Hypoxia, hypoperfusion (local or systemic shock), metabolic derrangements (hypoglycemia), expanding mass, increased pressure, edema ABCs first! History Details of injury mechanism Fall: height and surface type MVC: Use of restraining devices, speed Action of victim (thrown, rolled, etc) Timing of symptoms LOC, amnesia, confusion, seizure, vomiting, headache, general behavior Risk factors: Seizure d/o Adolescent: drugs/intoxication Physical Exam Mental Status!! Use the Glasgow Coma Scale Examine head for obvious evidence of trauma Severe brain injury/trauma may be present in a patient who has NO external signs of trauma Neurologic exam Look for focal findings Fundoscopic exam: look for retinal hemorrhages A patient presents with blood draining from his ears, ecchymoses in the orbital area, and postauricular bruising. He likely has what type of fracture? A. Basilar skull fracture B. Simple linear skull fracture C. Scapula fracture D. Depressed parietal skull fracture E. Femur fracture Basilar Skull Fracture Ecchymoses in the orbital area Blood behind the TM Battle sign (postauricular bruise) Temporal Bone Fracture Bleeding from the external auditory canal or hemotympanum Hearing loss Facial paralysis Cerebrospinal fluid otorrhea Has an ICI occurred? Clear predictors: GCS ≤ 14 or altered mental status Focal neurologic abnormalities Skull fracture Yet many people with ICI lack these features…when do we do imaging? Consider children < 2 years old separately More difficult to assess, more easily injured from short falls, higher incidence of asymptomatic injuries, more often victims of inflicted injury What type of intracranial injury is this? A. Subdural hemorrhage B. Subarachnoid hemorrhage C. Epidural hemorrhage D. Cerebral Contusion E. Diffuse axonal injury Focal Hemorrhage: Epidural Lens-shaped; often has overlying fracture “lucid interval” common on Boards only Subtle signs: vomiting, headache, often asymptomatic can progress rapidly Subdural Crescent-shaped; can be bilateral Associated with underlying brain injury Present with LOC, AMS, lethargy Suspect NAT Subarachnoid Rarely associated with mass effects Usually seen with other ICIs Present with LOC, headache, meningeal irritation Cerebral contusion Brain bruise: can have coup and contrecoup (brain striking skull) Present with subtle signs: vomiting, headache, LOC, ?focal neuro defect Diffuse Injury Diffuse axonal injury Injury to white matter due to shear forces Acceleration/deceleration or rotational forces (MVC) Present in coma or less commonly like a concussion CT scan with small areas of hemorrhage near gray-white interface Cerebral edema Severe head trauma May not be visible on initial imaging Present with marked depression or deterioation of GCS Main threat: increased ICP Headache, vomiting, depressed mental status Posturing and vital sign deterioration Bradycardia, hypertension, abnormal respirations Ultimately, can lead to brain herniation Repeated fundoscopic examinations are important to look for papilledema Especially for patients with coma or seizure May not be present initially 4 possible types Uncal herniation Innermost part of temporal lobe moves over tentorium Exerts pressure on the midbrain and CNIII Leads to ipsilateral pupillary dilation A 12-year-old boy is brought to the emergency department after being struck by a car. On physical exam, he is unresponsive and has a large abrasion over his forehead. His heart rate is 100, respiratory rate is 8 breaths/min and shallow, and blood pressure is 130/80. His pupils are unequal. Of the following, the MOST appropriate INITIAL step is to: A. Administer tetanus prophylaxis B. Infuse 20 mL/kg of 0.9% saline C. Obtain head computed tomography scan D. Provide assisted ventilation E. Administer mannitol ABCs FIRST! Cervical spine precautions Oxygen Ventilation as needed to keep pCO2 34-45mmHg Hyperventilation has a limited role GCS<8 = intubate Drugs Cardiovascular support Anticonvulsants for seizures Medications to decrease ICP Mannitol Hypertonic saline Hospital admission Any depressed skull fracture ICI Normal CT scan but persistent symptoms (persistent vomiting, severe headache, abnormal mental status) Emergent Neurosurgical consultation Depressed skull fracture and any ICI D/C home? Normal CT scan (or no CT scan indicated) Resolution of symptoms Child is easily aroused to light touch, normal baseline mental status; normal neurologic exam If vomited: can now tolerate PO fluids Reliable caregiver No concern for inflicted injury Always review symptoms concerning for ICI! Return for: persistent or worsening headaches, development of vomiting, change in mental status or behavior, unsteady gait or clumsiness/incoordination, seizure Arrange follow up (even if by phone) in 24 hours Wake up? For low-risk mechanism, no LOC or mental status changes, <1 episode of vomiting, no non-frontal scalp hematomas Observe, do not need to keep them awake, check them periodically No data available for waking child up If concerning mechanism or prolonged symptoms: Can wake up every 4 hours: child should be able to recognize parent and surroundings and appear alert Subluxation of the radial head Typical patient: Age < 6 years History of pull on the arm by caretaker, sibling, etc Patient holds arm partially flexed and pronated **refuses to move it voluntarily** Reduction is initially painful but discomfort quickly resolves and patient begins moving the arm voluntarily If uncertain of diagnosis or if reduction is unsuccessful xray! Name this type of fracture: A. Buckle fracture B. Greenstick fracture C. Nursemaid’s elbow D. Salter-Harris Type 1 E. Salter-Harris Type 4 Bones tend to BOW rather than BREAK Buckle (torus): compression fracture Metaphyseal fractures Circumferential compression but no periosteal rupture Greenstick Incomplete fractures of diaphyseal or metaphyseal bone Intact bridge of cortex and perisoteum on the compression side Plastic deformation: in very young children, neither cortex may break 20% of all childhood fractures occur at the physis Can disrupt bone growth Clavicle fracture AC separation Injuries that affect vasculature You are seeing a 5 yo boy who complains of right arm pain after a fall while jumping on the bed. He is holding his right arm against his body and is unwilling to move it. He has no deformity or swelling of his right arm, but he does have a tender swelling in his mid-clavicle. You obtain a radiograph which shows a midshaft clavicle fracture. Of the following, you are MOST likely to advise the parents that: A. Complications include ulnar nerve palsy B. He should be tested for osteogenesis imperfecta C. His right arm should be placed in a sling D. Surgical reduction will be needed E. The injury typically heals in 8 to 10 weeks which will be done in foster care because you are reporting them to OCS Common fracture of childhood Majority are mid-shaft or distal Caused by fall or direct force onto lateral shoulder (with arm adducted) Presents with pain, deformity, swelling, unwilling to move arm Rare complications: brachial plexus injury (more common with distal fracture) Treat: Immobilization with either figure of eight bandage or sling Adolescent male athletes Fall onto shoulder with arm adducted or direct blow to lateral shoulder Ranges from partial to full separation Swelling and tenderness over AC joint; pain with arm elevation and crossing over across chest Treatment: Partial: immobilization Complete: surgery Normal Shoulder 60% of elbow fractures in children High incidence of neurovascular injury Nerves: radial, median or ulnar Vascular: brachial artery More common with posterolateral displacement of distal segment Look for pallor and worsening pain Tibial fractures: watch for compartment syndrome in the distal lower extremity Scaphiod fracture of the wrist: at risk for ischemic necrosis Posteriod sternoclavicular dislocations: dislocated proximal clavicle may compress the upper airway or subclavian vessels Prior to the development of various thermometers, a temperature of 98.6 became synonymous with “normal” body temperature Body temperatures vary depending on multiple factors Method of assessment (axillary, oral, rectal, tympanic) Mean range of 97.5-98.6 Time of day: lowest in morning, peak in early evening Individual factors Age (slightly higher in younger infants) Sex Physical activity Ambient air temperatures There are various methods used to measure body temperature…consistency is important Axillary Skin temperature lags behind core temperature, especially early Low sensitivity, often inaccurature and imprecise Oral method Safe and comfortable in kids > 5 years Less lag time and more accurate than axillary measurements Affected by temperature of recently consumed foods or by evaporative effects of mouth breathing Rectal temperature Has long been accepted as the gold standard of indirect measurement Standard of care in febrile neonates Less deviation by environmental factors Uncomfortable Associated with cross-contamination Infrared tympanic membrane thermometry Quick, comfortable, cost-effective Blood supply to the TM is similar to that of the hypothalamus, so measurement is thought to be closer to core body temperature Accuracy remains debatable You are evaluating a 4 month old baby with fever up to 101.5 for one day. On ROS and physical examination, there are no localizing signs for the fever. What is your problem definition? A. 4 mo F with otitis media B. 4mo F with urinary tract infection C. 4 mo F with fever of unknown origin (FUO) D. 4mo F with thermometer malfunction E. 4mo F with fever without a source Fever without localizing signs on the physical exam Both the differential diagnosis and the management differ depending on the age of the child Infants < 3 months Immature immune response and may no be able to contain certain infections Do not consistently show signs of a “localized” cause for fever, so they often undergo lab evaluation < 28 days = FULL septic evaluation 70% have infectious cause identified, majority are viral 10-12% of febrile infants have bacterial illness UTI, meningitis, sepsis, bacteremia, osteomyelitis, septic arthritis, PNA Pathogens: GBS, Listeria, Salmonella, E. coli, Staph aureus 3-36 months Most common age for febrile illness, but up to 60% have a “localized” bacterial or viral cause 40% of cases do have fever without a source Primarily viral that requires only reassurance and careful follow-up Occult bacterial infections are still present but less common Bacteremia…depends on immunization status UTI Prevalence from 2-9% More common in young girls, least common in circumcised males If suspected…obtain catheterized urine culture Pneumonia You are telling mom how to treat your 4mo patients fever at home (once you determine that she is at low risk for serious bacterial infection and that she likely has a virus). What antipyretic agent do you recommend? A. B. C. D. E. Ibuprofen or another NSAID Acetaminophen (Tylenol) Both Ibuprofen and Tylenol alternating with each other q3 hours Neither…give the baby an ice bath Neither…wipe the baby down with alcohol Should begin with restoring the nutrients and water lost during the onset of the febrile phase Proper hydration Comfortable environment Sponge bathing with tepid water only provides marginal temperature reduction and often causes discomfort and shivering Cold water or rubbing alcohol should NOT be used because it leads to vasoconstriction…which does not allow for heat dissipation Alcohol can be absorbed through the skin and leads to toxicity Acetaminophen 10-15 mg/kg every 4-6 hours NSAIDs (most commonly Ibuprofen) 5-10 mg/kg every 6-8 hours Do NOT use in children < 6 months of age due to the risk of interstitial nephritis Similar safety and analgesic effect for moderate-severe pain Ibuprofen is a more effective antipyretic and provides a longer duration of antipyresis. No current evidence indicates that alternating drugs is either safe or more efficacious than single-drug therapy. This is a _________ degree burn. A. B. C. D. E. First degree Second degree Third degree Fourth degree Fifth degree First degree burns Superficial Dry Painful to touch Heals in < 1 week Ex: prolonged exposure to sunlight Second degree burn Partial thickness Pink or mottled red Bullae or frank weeping on the surface Usually painful unless classified as “deep” Heals in 1-3 weeks Ex: commonly caused by scald injuries, brief exposure to heat Third degree burn Most serious Appears pearly white, charred, hard, or parchmentlike Dead skin (eschar) Superficial vascular thrombosis can be observed PainLESS A superficial burn wound that extend to less than 10% of the TBSA can usually be treated on an outpatient basis UNLESS abuse is suspected Apply cotton gauze occlusive dressing Protects damaged skin from bacterial contamination Eliminates air movement over the wound (decreases pain) Decreases water loss Change dressings daily Topical antibiotic before dressing is placed for prophylaxis Most common = silver sulfadiazine Daily clinical inspection and wound culture, if necessary, should determine when the wound is healed Typically within 2 weeks More extensive or severe burns require inpatient management, typically at a specialized burn center Initial management Initial assessment and removal from the scene Aggressive fluid resuscitation Nutritional support Airway management Prevention and treatment of complications Sepsis is major cause of mortality Burn shock and burn edema Hypermetabolism Pediatric electrical burns are typically related to contact with household, low-voltage sources like electric cords and wall outlets (110 Volts) Burns Direct contact burns Flash contact = current strikes skin but doesn’t enter the body, associated with soot Arc-exposure = body becomes part of the electrical current Associated with deep tissue burns and internal organ involvement Extent of injury may be underestimated Complications (more likely with high-voltage…>1000V) Infection…so MUST ensure immunization status Arrhythmia (asystole and ventricular fibrillation) Compartment syndrome, rhabdomyolysis, renal damage Decontamination of the wound is the most important step in preventing infectious complications Tap water, sterile water, and sterile saline are all safe and effective Pressure irrigation 4-15 psi using a syringe and splash guard 100mL/cm of wound Effective at removing most bacteria and foreign material Removing foreign material is essential to minimize the risk of infection Wound should be explored for retained foreign bodies Heavily contaminated wounds (“road rash”) should be scrubbed. Anesthesia may be required to achieve satisfactory cleaning. Once the wound has been evaluated, decontaminated, and repaired, an appropriate dressing should be applied. Wounds heal best under slightly moist conditions Application of topical antibiotic ointments (bacitracin) and an occlusive dressing Dressing can be left in place for 24-48 hours Change once or twice daily Wounds that cross joints may require splinting or bulky dressings to minimize movement and tension on the wound You are evaluating a teenage patient with extensive dog bites to the left lower leg and foot as well as the right hand…he got these when breaking up a dog fight with his friend. He is unsure of his immunization status, and his parents are on vacation out of the country, so he can’t ask them. What do you need to do for tetanus prophylaxis? A. B. C. D. E. Nothing…you aren’t worried about tetanus at all. Tetanus immune globulin only Tdap vaccination only Both Tdap and tetanus immune globulin injection Call a consult to ID…you have no idea! (Both Dr. Begue and Dr. Seybolt are on vacation…ahhhhh!!!) Clinical Manifestations Most are plantar surface wounds from nails Infected puncture wounds that result from a nail through a tennis shoe should be evaluated for possible Pseudomonas aeruginosa infection Punctures also occur in other parts of the extremities, trunk, and head Particular attention should be paid to wound depth, possible retained foreign bodies, and risk of infection Inspect and remove superficial debris Neurovascular evaluation Copious irrigation High pressure irrigation is contraindicated because it may trap bacteria or debris deep within the puncture site Radiographic evaluation for retained foreign body X-ray Ultrasound: highly sensitive CT scan Higher risk of infection Older than 6 hours Occur from bites, particularly mammalian bites Cat >> human > dog Should heal by secondary intention Retained foreign body or vegetative debris Extend to a significant depth Human bites on a clenched fist (inoculation of the MCP joint capsule) Most can be managed in the outpatient setting with antibiotic dressings and warm soaks. Oral antibiotics only for puncture wounds with a high risk of infection Augmentin OR Clindamycin and Bactrim if PCN allergic for bites to the hands or feet Close follow-up Any fever, wound redness, swelling, pain, or pus should prompt re-evaluation to rule out persisted foreign body or infection Staph aureus Strep pyogenes Pasteurella multocida and other anaerobes (mammal bites) More serious infections may need additional imaging and IV antibiotics Cellulitis Abscess Osteochondritis Osteomyelitis Surgical consultation for potential debridement or retained foreign body removal should be considered for wounds that are refractory to medical management Two very brilliant past pediatric residents (Dr. Kathy and Dr. Adrienne) walked into the room of a patient with a forehead laceration that extends slightly to the bridge of his nose. They decide to use tissue adhesive to repair the small wound. What could they have done to prevent gluing their patient’s eyelids together and having to remove a few eyelashes to get them apart??!! They wish they didn’t have to worry about getting sued by the patient’s dad…who is a lawyer! A. B. C. D. E. Hook the patient up to an EKG to monitor for arrhythmia Consult their co-residents Dr. Chelsey and Dr. Nicole to help pry the eyelids apart. Try to rinse off the adhesive with some tap water Apply petroleum jelly or vaseline to the eyebrow and eyelashes beforehand to prevent the adhesive from sticking Repeat their 3rd year of residency! Evaluate the laceration for foreign material and for any signs of neurovascular damage Anesthetics Topical LET Subcutaneous injection of lidocaine through the opening of the wound edge No epinephrine for fingers, toes, penis, pinna, nose Regional nerve blocks Anxiolysis Benzodiazepines (PO or intranasal Versed) Distraction techniques Timing of closure Face: within 24 hours Anywhere else: within 6-8 hours Tissue adhesives Less painful, reduced procedure time, comparable cosmetic outcomes Recommended for Linear lacerations Low tension < 4cm in length Simple interrupted repair “Rule of ones” Removal: 3-5 days for face and scalp; 10 days elsewhere Lip lacerations Require special care if the injury crosses the vermilion border Technique Approximate the vermilion border with a nonabsorbable or “stay” suture. Failure to do so will result in a poor cosmetic outcome An infra-orbital or mental nerve block along the lower gum line may be considered to reduce tissue distrotion for lip lacerations Occur in up to 8% of children with cutaneous wounds Wound dehiscence Delayed healing Poor cosmetic outcome Potentially serious morbidity Tension on a wound overcomes the tensile strength of the repair Can be minimized by splinting high tension wounds and the appropriate choice of material for repair Wound infection Higher risk Extremities, joints >12-24 hours old Crush, tear, bite, and puncture wounds Please see the Morning Report PowerPoint entitled “Bites” on the Chief Resident Webpage. It covers most of the additional content specifications for management of animal and insect bites in detail. •Hymenoptera stings •Life-threatening reactions include hypotension, wheezing, laryngeal edema, and other signs of anaphylaxis •If a patient has one anaphylactic reaction to hymenoptera, he should be reffered to AI (and given an epipen, of course) •Immunotherapy with insect venom is 98% effective in preventing subsequent reactions
